Racial and ethnic amputation level disparities in veterans undergoing incident dysvascular lower extremity amputation

Abstract

Background The choice of incident amputation level can have a profound effect on clinical outcomes. Amputations at the transmetatarsal (TM) or transtibial (TT) levels result in greater preservation of function and mobility, whereas transfemoral (TF) amputations typically result in a greater adverse impact. Prior investigations have explored racial/ethnic and regional variation in incident amputation level. This study overcomes some of the methodological limitations seen in prior research through the use of a large national, multiyear veteran sample and by including only those who have undergone an incident amputation. Objectives (1) Determine if there are national/regional differences in the frequency of incident TF amputation compared with TM and TT amputation, (2) Determine if race/ethnicity and geographic region are associated with incident TF amputation level, and (3) Determine if racial/ethnic disparities of incident TF amputation differ by the presence of diabetes or prior revascularization. Design Retrospective cohort study of veterans undergoing an incident dysvascular lower extremity amputation. Setting One hundred ten Veterans Affairs (VA) Medical Centers. Participants Seven thousand two hundred ninety‐six Veterans undergoing incident unilateral dysvascular lower extremity amputation identified in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database (2005–2014). Interventions Not applicable. Main Outcome Measure Incident amputation level. Results The White, Black, and Hispanic risk for an incident TF amputation was 31% (n = 1356), 35% (n = 810), and 46% (n = 293), respectively. In the Continental region, Blacks who had not had a prior revascularization were more likely to undergo a TF amputation compared to Whites both with and without diabetes (odds ratio [OR] = 1.4; 95% confidence interval [CI], 1.1, 1.9 and OR = 1.5; 95% CI, 1.1, 2.1, respectively). In the Southeast region, Hispanics compared with Whites were at increased odds of undergoing a TF amputation, irrespective of a diabetes or a prior revascularization (ORs ≥ 2.9). Conclusions Racial and ethnic disparities exist in choice of proximal compared with distal amputation in specific VA geographic regions.

Association of Health Care Utilization and Access to Care With Vascular Assessment Before Major Lower Extremity Amputation Among US Veterans

“…Black patients undergo LEA at higher rates than White patients; this finding has been shown for both veterans and civilians . Several possible explanations for this pervasive racial disparity have been proposed, including more aggressive atherosclerotic disease burden, patient presentation later in the course of disease, and a lower likelihood of being offered revascularization, which subsequently results in a higher rate of primary LEA .…”

“…Black patients undergo LEA at higher rates than White patients; this finding has been shown for both veterans and civilians. 13,[17][18][19][20][21][22][23] Several possible explanations for this pervasive racial disparity have been proposed, including more aggressive atherosclerotic disease burden, 24-26 patient presentation later in the course of disease, 17,18,22,27 and a lower likelihood of being offered revascularization, which subsequently results in a higher rate of primary LEA. 17,[28][29][30][31] The findings from our study appeared to contradict some of these potential explanations; specifically, we found that African American or Black veterans were no less likely than White veterans to have an arterial blood flow assessment or revascularization in the year prior to LEA.…”